Plan Review Application for Tattooing or Piercing

2) If you do not enter a required field your application will not be submitted and you will have to re-upload any documents you submitted.

3) If you have any trouble filling out this form you may fill out the pdf version (found on our website www.fcss.mt.gov) and mail it in with copies of the required documents or contact Melanie Shaw at (406) 444-2823 or Ed Evanson at (406) 444-0067.

County
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STOP! Do not fill out and submit this form. Gallatin and Yellowstone Counties have their own licensing programs.

Additional Documents

ALL NECESSARY DOCUMENTS MUST BE RECIEVED BEFORE APPROVAL

If you have trouble uploading documents you may fax them to (406) 444-5055 IMPORTANT - put your name and ATTN Ed Evanson/Melanie Shaw on the Fax or mail them to DPHHS Food And Consumer Safety, PO Box 202951, Helena MT 59620-2951 or emailed to eevanson@mt.gov or mshaw2@mt.gov

Copy of Photo ID

Scan and upload a copy of your photo I.D. here

Copy of Consent Form

upload a copy of your consent form in word or pdf here

Floor Plan

Upload a scanned copy of your floor plan or a CAD file here

Spore test results form a certified lab (if autoclave used)

Upload a copy of your spore test here

Water Test Results

Only submit these if you are on a private well. Results must be from a certified lab.

Documentation of 1st Aid Training

Upload a copy of your 1st Aid certificaiton here

Documentation of Bloodborne Pathogen Training.

Upload a copy of your BBP certification here

General Facility Requirements

Read carefully and mark yes if your establishment meets the following criteria

All areas with client access are clean, free of unnecessary items, dust and fumes. All other adjacent rooms are separated by closed doors, free of insects and rodents, and not a source of airborne hazardous chemicals or fumes. Light is adequate throughout the facility. Private living or sleeping rooms are separated by solid self-closing doors.
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Water Supply

Read carefully and mark yes if your establishment meets the following criteria

Water supply has adequate pressure and volume. If it is a public water supply then there are no outstanding deficiencies with DEQ rules and no contamination. If private, then coliform tests are taken twice a year (April - June, ; August - October); nitrate tests are taken before opening, then at least once every three years. Any water that is not suitable for drinking is labeled "not for human consumption". No hose is attached to a faucet without a backflow prevention device installed. All construction, extension, alteration, repair, or replacement meets state and local laws. Bottled water is from an approved source and protected from contamination.
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Sewage System and Solid Waste

Read carefully and mark yes if your establishment meets the following criteria

The sewage system is adequate and safe. If it is public, then the system meets DEQ requirements and is without any evidence of failure. Mop water/dirty water is dumped in the mop sink or toilet. Garbage storage is adequate and prevents nuisance. Garbage (other than infectious waste) is sent to the facility listed below at least weekly.
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Name of Solid Waste Facility
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Toilets and Handwashing Facilities

Read carefully and mark yes if your establishment meets the following criteria

A bathroom with a handwashing sink is conveniently located for clients and artists, within 200 ft and not more than one flight of stairs from the establishments door. The bathroom is vented, and well lit. The bathroom is supplied with toilet paper and a garbage can and the floors, walls, ceilings are in good repair and clean. There is no storage of tattooing/piercing supplies in the bathroom. The handwashing sink is in the bathroom or within 10ft of the doorway. The handwashing sink has hot and cold mixing water. With soap, paper towels, and garbage cans conveniently located near the handwashing sink.
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Work Room

Read carefully and mark yes if your establishment meets the following criteria

No tattooing or piercing is done outside of designated work room. The work room has a barrier from other areas that is closable. Swinging half-doors are an example. The work room is not a corridor for access into other rooms.
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Animals are not allowed in the work room except for trained service dogs. 50-foot candles of light are required at the level of procedure. Spot-lighting is ok. The ventilation is adequate (This means normal humidity levels, no fumes or heavy odors. Mechanical ventilation is not required unless conditions give reason for it.) Filters to heating/air conditioning ducts are checked and replaced as needed. Outer doors and windows are screened or kept closed. Hand washing sink is within work room or within 10 feet of the doorway.
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Handwashing sink needs to be accessible to the artist at all times and not in a public restroom. If hand sink is outside of the work room, then the doorway must have a two-way self-closing door. Paper towels must be used to turn off the faucet when foot or wrist controls are not available. The handwashing sink is sanitized daily. The handwashing sink provides hot and cold mixing water and there are soap, paper towels, and garbage cans that are conveniently located near the handwashing sink.
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Garbage cans are uncovered to prevent hand/glove contamination when in use and covered when not in use. Garbage cans are emptied from the work room daily. Sharps containers are available for needles, etc. Sharps containers do not have to be removed from the work room daily. Work room is clean. Floor is smooth, non-absorbent, and wet-mopped daily. Tobacco use, eating, and drinking is not allowed in the work room, except eating and drinking is permitted for first aid purposes only.
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Temporary or Mobile Establishments

Only fill out the next two questions if you will be operating a temporary or mobile establishment.

If no water heater is available, room temperature water may be used as long as the system meets requirements for potable water systems. Please describe the proposed system in detail.

Portable toilets must be emptied in an approved system. Please describe how and where you will dispose of sewage and other wastewater.

Equipment and Supplies

Read carefully and mark yes if your establishment meets the following criteria

Equipment, tools, and jewelry are clean, in good condition and rust-free. Sharp instruments are sharp. Defective items are not used. Items intended for single-use are not reused. Gloves are used once, they are nonlatex, and designed for medical use.
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A durable tray is used for items that will be cleaned and autoclaved. Needles are only used once, and then discarded directly in a sharps container. Needles are not bent or broken before disposal.
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Counter tops, tables, and chairs are washable, in good repair, cleaned and sanitized between clients. There are enough sterile supplies, disinfectant, antiseptic, and gloves for three working days. Chemicals/cleaners are stored to prevent spilling, fumes, or contamination. They are labeled with the common name of the material and used according to the manufacturer’s instructions. Any article that comes into contact with the client is stored in closed, clean containers or cabinets. Tables, trays and equipment are not shared between artists serving different clients at the same time.
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Bloodborne Pathogen Exposure Control

Read carefully and mark yes if your establishment meets the following criteria

Number of employees

Do not include business partners, independent workers, or volunteers

If you have at least one employee, then OSHA standards 29 CFR 1910.1030 must be met. A copy of this document can be found at www.osha.gov

Sterilization of Equipment and Jewelry

Read carefully and mark yes if your establishment meets the following criteria

Nondisposable instruments that come into contact with blood or body fluids are individually wrapped and autoclaved and/or come from the supplier individually wrapped and sterile. If you use jewelry it is individually wrapped and autoclaved, or comes from the supplier individually wrapped and sterile.
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When an autoclave is used, packaging designed for autoclaving and a temperature indicator is used every time. The autoclave completes the cycle every time it is run (15 PSI, 250oF/121oC, 20 minutes). If the autoclave is not designed to reach 15 PSI, 250oF/121oC for 20 minutes, please include a copy of the manufacturer’s instructions. Autoclaved packages are dated and initialed by an artist. Autoclaved items not used within 6 months of the sterilization date, or in a package worn away or torn, are re-wrapped and autoclaved. A spore test is completed by a certified lab before opening to the public, and at least every month thereafter, and whenever the autoclave is moved. Sterile packages are only opened in front of the client. artists serving different clients at the same time.
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If you use an Autoclave list the Manufacturer and Model number below

Sterile packages are only opened in front of the client, and artists are not serving different clients at the same time.
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Cleaning and Ultrasonic Use

Read carefully and mark yes if your establishment meets the following criteria

Reused instruments must be cleaned with appropriate soap/detergent and rinsed completely - list the type of soap/detergent you use below

Do sinks used for cleaning instruments have hot and cold water and are they deep enough to submerge instruments.

If hot water is not available describe your provisions for cleaning below

Ultrasonic units are used according to the manufacturer’s instructions, always covered when used, and not used instead of autoclave sterilization. Cleaning, ultrasonic unit use, dusting and vacuuming are not done at the same time clients are being tattooed or pierced.

Skin Preparation, Aseptic Technique, and Aftercare

Read carefully and mark yes if your establishment meets the following criteria

Sterile instruments and aseptic technique are used at all times during the procedure. Hands are washed before and after every procedure, with warm running water and soap for at least 20 seconds, scrubbing under fingernails, rinsing with clean water, and drying with a clean paper towel.
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Outer clothing is clean. Hair restraints are used to keep hair from contacting the client if needed. Personal accessories are kept from touching the client.
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Razors for shaving are used once. Straight razors and replaceable blade units are not used. After shaving the client, the artist washes hands, washes the client’s skin, and changes gloves (if used). Before the procedure, the skin is thoroughly dampened with an antiseptic using clean cotton, gauze or tissue. Marking devices are used only once. New gloves are put on before each procedure. If gloved hands are contaminated during the procedure, hands are rewashed and new gloves are put on before continuing with the procedure. (Examples of contamination are touching eyes, nose or mouth, answering the phone, opening a door, touching a book or paper, or retrieving an item from the floor.) If the artist sustains a needle stick, the artist washes the punctured area and hands, then regloves, and uses a new needle before continuing the procedure.
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Handling and Disposal of Infectious Material

Read carefully and mark yes if your establishment meets the following criteria

Adequate supplies of sharps containers are available. They are closed securely for disposal. Adequate protection is used to clean up broken glassware, such as using a brush and dustpan. Hands are washed and regloved after cleaning up spills. Laundry that may have been contaminated with blood or body fluid is stored separately in a closed leak proof container or bag. Waste (other than sharps) contaminated with blood or other bodily fluid is placed in a garbage container labeled “biohazard” or , lined with a strong leak proof plastic bag, tied to prevent leakage for handling, and placed in rigid leak proof containers for storage and transportation. (This waste is considered contaminated but not “infectious”. Examples are gloves, tissues, or ink cups. Once closed securely and removed from the work room, it can be placed with other regular garbage for disposal.)
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All infectious waste (sharps, free-flowing blood or body fluids, items soaked in blood or body fluids) is autoclaved/incinerated by the following entity
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If you are an Ear Piercing Only establishment and you will not have any sharps to dispose of put N/A in this box.

Record Keeping and Review

Read carefully and mark yes if your establishment meets the following criteria

Client records, consent forms, autoclave spore test results and any other records required by the health authority are kept on the premises for at least 3 years, made available for review by the health authority, and typed or printed in ink.
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Client Record and Consent Form

Read carefully and mark yes if your establishment meets the following criteria. Your Consent form will not be approved if it does not meet these minimum criteria. WE HIGHLY RECOMEND YOU USE THE SAMPLE CONSENT FORM FOUND AT http://www.dphhs.mt.gov/publichealth/fcs/tattooing.shtml under useful links and forms.

Client records include a copy of the signed consent form, the name of the artist performing the procedure the establishment location address and phone number. Any special instructions or information about the client’s medical or skin condition which is relevant to the procedure. A written physician referral if the client is taking any drug or dietary supplement that may induce bleeding tendencies or reduce clotting, has a medical condition that is known to cause bleeding tendencies or reduce clotting, shows signs of recent intravenous drug use, has a sunburn, skin disease (e.g. psoriasis or eczema), skin infection, or a lesion such as a mole at the procedure site. *

The client signs a consent form before each procedure (even if a returning customer). A parent or legal guardian signs in person for any client under the age of 18.
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The consent form includes the client’s name, address, date of procedure, design of tattoo (if applicable), location on client’s body, and any other appropriate information. A description of potential complications and side-effects including abscesses, allergies, excessive bleeding (from body piercing), heavy metal poisoning, infection, keloid formation, muscle paralysis, nerve paralysis, scarring, swelling, bloodborne pathogens, tongue swelling, throat closure, and tooth fracture (from oral piercing). The symptoms of infection such as fever, swelling, redness or drainage and instructions to consult a physician if symptoms of infection or other complications occur. That the procedure is permanent. That the client consents to the tattooing or piercing procedure. The form states the client received aftercare instructions verbally and in writing before the procedure. *

Training

Read carefully and mark yes if your establishment meets the following criteria.

The above trainings have been completed within the last 12 months. A new artist will complete training prior to working in a licensed facility.

ALL ARTISTS WILL RENEW TRAINING BEFORE EXPIRATION.
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License Requirement and Display

Read carefully and mark yes if understand the requirements

Once you receive your license, it must be displayed in view of your clients. The license is not transferable. This means if you sell your business to another person, he/she must apply for a new license. If you move to a new location, you must apply for a new license. If you remodel your building, add work areas, or change plumbing, you must contact the health authority for a review and approval of your changes.

Notice: Obtaining a license from the health authority does not relieve the applicant from satisfying applicable requirements from other federal, state, or local agencies (such as building code permits and inspections, fire and life safety inspections, and other business licenses).
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Tattooing Requirements

Read carefully and mark yes if your establishment meets the following criteria. Then fill in the appropriate boxes.

All inks are designed for tattooing. They are labeled with the manufacturer and lot number. Inks are kept in the original container. Inks are mixed according to manufacturer’s instructions and placed in clean sterile containers. Artists who are aware of any reaction, allergy, or sensitivity must report the condition and ink information to the health authority. Inks disapproved or under recall by the FDA are not used. Individual portions of ink are used for one client, and then properly discarded. Ink cups are not re-used. When adding ink to a portion cup (or any container), a paper towel or tissue is used to prevent gloves from being contaminated, or new gloves are put on. If using stencils, they are cleaned and sanitized between clients. Carbon paper is used only once.
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Any product used to transfer a pattern is single-use or portioned out from a container in such a way that it does not become contaminated. Describe product and the method of dispensing that product.
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List the brands of Inks you will be using.
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List the suppliers for your inks.
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Piercing Requirements

Read carefully and mark yes if your establishment meets the following criteria. Then fill in the appropriate boxes.

Notice: For a list of restricted practices not included under the provisions of this license, please refer to the Administrative Rules of Montana 37.112.165.

If piercing clients under the age of 3, a choking hazard warning is given to the parent or legal guardian. (An example is available from the health authority).

The piercing area lighting is not 50 footcandles, but is a minimum of 30 footcandles at the level where the ear piercing is being performed. (This can be determined at the time of inspection. Most normal room lighting meets the 50 footcandles requirement.)

EAR LOBE PIERCING ONLY ESTABLISHMENTS use if an exemption is necessary.

Piercing area does not have a physical barrier. The following is a description of how the work area is separated enough from other areas so that no physical contact can be reasonably expected to occur between the general public and the client or artist:

EAR LOBE PIERCING ONLY ESTABLISHMENTS fill out if an exemption is necessary.

Hand washing sink is not available within the work room or within 10 feet of work room. The following is a description of accessibility to a hand washing sink, hand sanitizer type and glove use protocol

Signature

Approval of these plans and specifications by the health authority does not indicate compliance with any other code, law or regulation that may be required. It further does not constitute an endorsement or acceptance of the completed establishment. A pre-opening inspection with equipment will be necessary to determine compliance with the rules governing tattooing and/or piercing establishments. I hereby certify that the above information is correct. I fully understand that any deviation from the above without prior permission from the health authority may nullify any approval from the health authority. I fully understand that approval of these plans and approval of the license does not endorse any activities beyond the scope of the rules pertaining to tattooing and body piercing, such as activities that may constitute medical procedures or medical practice.
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